GW1--02881_Well Construction - GW1_20240510

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WELL CONSTRUCTION RECORD(GW 11 For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14:.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 66 130 il: 2 GPM,
NC Well Conhactor Certification Number 230 ft• 240 R• 4 GPM
.1.5.OUTBRCASING(for.muitkileed:welli):ORLUNER(ifa llcablep` '.:, ;r ;;,
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 66 ft• 61/4' in. SDR21 PVC
METER, THICKNESS MATERIAL
2.Well Construction Permit#:OSWP202447916 FROM TO oR TOBING Igeritherniii,i >
List all applicable well consancttonperrnits(Le.UIC County,State,Variance,etc) ft. ft. In.
3.Well Use(cheek well use): ft R. in
Water Supply Well: 17.SCilEEN•`::.':`: ;:: . .. :: . .. .:
©Agricultural �Mrmicipa1/PubliC •
FROM TO DIAMETER' 'SLOT SIZE. THICKNESS MATERIAL
0 ft in.,
°Geothermal(Heating/Cooling Supply) ()Residential Water Supply(single)
ft. it. In..
°IndustrialCommercial °Residential Water Supply(shared)
riIaigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 e• HOleplug Gravity7
°Mom�g °Recovery ft. f. p 9
Injection Well:
ft.rj
tjAquifer Recharge ()Groundwater Remediation ft.t.aA4uifetStoregeandRecovery Salinity Barrier 19:SAND/GRAVELPACIE(tfabplkabte)•:'. :• :;..::, ::::..:::-.::.'.:.:.::.
FROM . TO MATERIAL EMPLACEMENT METHOD
r3Aquifer Test oStonnwater Drainage ft. ft. I.
°Experimental Technology °Subsidence Control ft. ft.
OGeothermal(Closed Loop) °Tracer 30.DRILLING LOG(Ittseh ddttfonel abaeta if new ears) .':..
°Geotthermal(Heating/Cooling Return) nOther(explain under#21 Remarks) PROM To DEscRtrnoN(ewe,t�@dr„en,sowmcktsPe,ante de,etc.)
4/24/24 202447916 15 Clay '
4.Date Walls)Completed: Well ID# 15 ft• 40 ft• Sandy Clay
Sa.Well Location: 40 ft. 56 fa Weathered Rock
Johnston Builders 56 ft. 66 ft. Solid Rock
Facility/Owner Name Facility MP fig applicable) 66 100 ft• brown rock ;-,.�... ,.._,a,:r Ji.L,
154 Crestview Acres Rd, Statesville 28677 112 IL 117 d• brown vein
Physical Address,City,and Zip ft. ft. MAY 1 0 2024
lredell 4752 85 7374 Z1:R>nhutics ;: :.
County .(PIN)
Parcel Identification No ��?Irk k
:ram t,
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwell field,one let/long is sufficient) 22.Certification:
35 43 45.404 N 81 49 26.199 W _ Iz't E'ta
6.Is(are)the wells)Jx Permanent or °Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certi that the wells)was(awe)constructed in accordance
7.Is this a repair to an existing well: DYes or %ONo with ISA NCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,jilt out knows well construction Information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#2I remarks section oronthe back of thtsfam,.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may Use the back of this page to provide additional well site details or well
construction,only I OW-1 is needed. Indicate TOTAL NUMBER of wells conshuction details. You may also attach additional pages ifnrr.s•y.
drilled 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:28$
Formulliplewel/slistalldepths(fdjgerent(e.vnple 3Q200'and2palot>7 ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
30 construction to the following:
•
10.Static water level below top of casing: (ft-) Division of Water Resources Information Processing Unit,If ester level is above casing use"+"
• 1611 Mail Service Center,Raleigh,NC 27699-1617
11..Borehole diameter:6 (in.) 24b.For Infection Wells:- In addition to sending the form to the address in 24a
12.Well construction method: Rotary above,also submit one copy of this iform within 30 days of completion of well
(Le.auger,rotary,cable,.direct push,etc.) construction to the following; I
FOR WATER SUPPLY WELLS Division of Water Resources,Underground Injection Control Program,
ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a,Yield(gpm)6 Method of test:weir 24c.For Water Sunni!,&Injection Wells: In addition to sending the form to
chlorine 14 OZ the address(es) above, also submit'one copy of this form within 30 days of
136.Disinfection type: Amount of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Envirownental Quality-Division of WaterResources Revised 2-22-2016